Is there any experience here with the light adjustable lens (LAL)?

Eye care
1

The light adjustable lens (LAL) received approval by the FDA in 2017. I’m now offered this IOL as an alternative to a monofocal one. Is somebody here with experience - referring to treatment and outcome?

There is a thread in the forum introducing the LAL but it’s three years old. They discussed the question whether the LAL is able to correct far, near and intermediate vision, achieving to be spectacle free at best. One member denied saying that you can only correct one distance like a monofocal lens. What is true?

Because I had rotation and unsucessful trifocal IOL treatment I very much appreciate the LAL with the possibility to correct the refraction several times after surgery when the lens is in place. Nighttime issues because of trifocal halos like concentric rings and spiderwebs around point light sources are not possible.

Sure there is the inconvenience to wear special sunglasses for several weeks from morning till dusk to protect the eyes from sunlight - even indoor and during showering but if it’s worth the outcome I wouldn’t mind.

Light Adjustable ?
What is a LAL IOL
2

This IOL requires special equipment so only a few Opthmalogist implant it. From the little I know in the US it is only being used as a monofocal, but the Codet Vision Institute is also trying out its ability in other configurations. You could call the Codet Institue and ask them about that, but I imagine when the IOL is configured other than a monofocal, one would get the same dysphotopsias associated with other defractive IOLs.

The big advantage is the ability to make post operatively adjustments and nail Plano or whatever your goal is.

If you decide to do monovision you would have the ability to accurately adjust the power the way you want.

Now what would be “Cool” is if they could configure the IOL for EDOF or as a Trifocal and then if you don’t like it post operatively change it back to a monofocal.

3

I’ll qoute from CODETVision:

“The LAL can correct near, intermediate, and distance vision, as well as astigmatism. It offers near vision correction using Extended Depth Focus (EDF) technology, which allows us to improve your near and intermediate vision without impacting your distance vision. Made of special photosensitive silicone material, the LAL is a glare-free, halo-free, shine-free solution.”

Sounds good! Sounds like freedom from spectacles or contact lenses. But how does it work in practice? If driving during day- and nighttime is needed as well as desktop-work with seamless vision from 40-80 cm?

Can you explain monovision? I heard of mini-monovision as well. What’s the difference?

4

I have no experience with them, and just have a standard monofocal lens. I have looked into them a bit. My conclusion is that they are not a presbyopia correcting lens, just a one distance monofocal that can be adjusted somewhat after implantation. I believe there is a limited time that they can be adjusted and then they become fixed. As far as I can see the only benefit is the ability to correct the power of the lens when the surgeon has miscalculated what power is needed. There could be some circumstances (high far sighted eye perhaps) where it is difficult to measure and calculate the required power where it could be of significant benefit. But on the other hand if the surgeon nails it for power, then it would seem to have no value at all over a standard lens. One would have to look at it in a lot more detail to see if there are any negatives, like the power drifting over time. I just have not investigated it. My second lens is most likely to be another standard monofocal in a monovision configuration.
.
Review of Ophthalmology does an annual survey of cataract surgeons to get some information about what is actually being used. I suspect it is a US surgeon survey mainly, so will reflect the lenses being used in the US. You could google the title of the article below for more detail. What I saw in it was the 6-7% of surgeons were considering the use of a light adjusting lens, but they gave no information on how many are actually using it. It is an interesting read to see what lenses surgeons are actually using of the various types of lenses on the market.
.
Review of Ophthalmology 15 JANUARY 2021 IOL Survey: New lenses turn surgeons’ heads

5

I found this article to be helpful in explaining what monovision is about.
.
Optimal Amount of Anisometropia for Pseudophakic Monovision Ken Hayashi, MD; Motoaki Yoshida, MD; Shin-ichi Manabe, MD; Hideyuki Hayashi, MD

6

If you decide to do monovision you would have the ability to accurately adjust the power the way you want.

That is a good point. It could be very useful for someone with cataracts so advanced that they cannot do a contact lens trial of monovision to determine how much of an under correction they prefer. It would give them the opportunity to refine it after the cataracts are gone and they can see well.

7

First, regarding EDOF, you need to see the defocus curve and ask how is the LAL achieving EDOF. EDOF use to mean a defractive IOl like Symfony, but now they have refractive lens, which provide only -.5D of EDOF, that they are calling EDOF IOLs like the IQ Vivity. If the LAL is being configured like the defractive IOLs EDOFs you will more than likely have dysphotopsias. But even if it is being configured like the IQ Vivity, IMHO there is no free lunch and you are getting that EDOF at the cost of contrast sensitivity. Hopefully the contrast lost is so slight most people would not even notice.

Now for monovision, micro monovision and mini monovision. Frankly I don’t know what the Diaptor difference between the 2 eyes breakdown is for category classification.I would only be interested in Micro Monovision which I classify as -.75D or less. The reason is the greater the Vision difference between the 2 eyes the greater the Stereopsis. Personally I would not recommend more than -2.0 D difference between the 2 eyes. I don’t have the links in front of me but there have been articles written on this subject matter.

Monovision was typically used with a monofocal, but it can also be used with an EDOF like Symfony or IQ Vivity to get better close vision. I would not think it would make sense to use it with a Trifocal like the PanOptix.

In monovision you are typically setting the dominate eye for Plano to get the best distance. The eye setting will depend on which IOL you are getting. Let’s say you are getting the IQ Vivity, which already gives you -.5D of EDOF. In that case you might set that non dominate eye IOL at -.75D to get an overall -1.25D of monovision.

So in the dominate eye you see great distance and in the non dominate eye you get better closer vision and then the brain neural adopts to present you with the best image for both far and near.
One of the biggest complaints with defractive IOLs is the dysphotopsias. So do your research and look at simulations and make sure you are 100% OK with the trade off to acquire close vision. Don’t let some Ophthalmologist sugar coat it do you research on it.

In full disclosure, I have the Tecnis MF in one eye and am waiting for the Synergy to be approved in the US and to see more data on that IOL as it is the one I currently want for my other eye.

8

I popped in here to see what others were saying about their experience with the LAL but it looks like I’m going to be the one sharing my experience and clearing up a few misconceptions.

First things first—I just had my left eye done with the RxLAL this past Tuesday. I’m 63 and had cataract in both eyes. I had it done in Cape Coral by a surgeon who was recommended to me by another cataract surgeon who got the same lenses put in 10 days prior to emailing me. So he is probably about 3 weeks in and LOVES them. He says that he has HD vision and I cannot fault him on his description.

I am not familiar with all the meanings of the different terms (like Presbyopia which is apparently farsightedness). I have always been nearsighted. Here is what I can tell you about my experience thus far.

  • Like everyone else seems to say about most cataract procedures, it was fast and painless.
  • You get 3 sets of UV blocking glasses that you can wear interchangeably (dark shades, clear lenses and what seem to be standard bifocal reading glasses, all made by or at least branded as RxLAL.
  1. The way it will work is you get the procedure and follow up the next day.
  2. Doc looks at your eye and how it is healing
  3. Follow up the following week to see how everything is proceeding
  4. If all is going well, you then follow up with him after the eye has completely or practically completely healed, at which point you will go through the standard refractive tests, “which looks better 1 or 2. Which looks better 3 or 4 and so on”. It is at this meeting (and subsequent adjustment meetings) where you confer with your doc your near and far seeing desires.
  5. Once these parameters have been decided on, they put you under some kind of UV exposure dudad and adjust the lens (which is very fast, I imagine a minute or so, I do not know since I have not had it done yet. They probably told me but I did not pay attention but it is fast). You them leave and continue to wear your UV blockers but now you are “test driving” these settings to see how you like them. I believe you do a total of about 2-4 adjustments over the course of 6 weeks total. All the while refining.
  6. When you are both happy with the settings, you then come in to “lock” the lenses and that is it, you no longer need to wear the glasses. It is however, imperative to wear the glasses for every waking hour until the lenses are locked in since random UV can change and also lock in the lens in some unknown state (or perhaps lock in some parts of the lens. In any case, that lens would have to be removed and I imagine it will be coming out of your pocket to redo it (+ another 6 weeks). There is no limit to how long they will remain “adjustable” as long as you keep wearing the UV blocking glasses but they told me that in general, the whole thing takes about 6 weeks from start to finish.

One thing to keep in mind is what my doc told me, “the good thing about these lenses is that once you lock them in, you have them for life. The bad things about these lenses is that once you lock them in, you have them for life.”

My results: I have only had it in since Tuesday and tonight is Friday. When I went in for my follow up on Wed, my eye was measured at 20/30. He told me that I was healing fast but had a little inflammation on one side of the eye. I don’t think (though I did not ask to confirm) that they have an initial “power” since they can be adjusted and are meant to be adjusted post-op. I will ask when I go back for my right eye on Monday. The very first time I came out and saw my hands, they seemed to be surrounded by an orange, 3D halo surrounding all the fingers, that disappeared after the first day.

There are absolutely no artifacts and no halos, no glare. As with probably most other lenses, the world is exploding with color and computer text is BLACK again and no longer gray or light gray. My right eye which WAS the better eye now looks like I am walking around looking at the world through a sheet of dirty, yellow plastic at a constant dust storm. I can no longer remember how bad my left eye was and it was much, much worse than my right eye.

The only thing I cannot see clearly is detail that is probably about 14-15" away. I can see the very close things if I put on the bifocals. I will ask him what range of vision I can expect when I see him again on Monday and Tuesday (Tuesday, he will do the follow up on both eyes and the following week when I go in for the right eye, he’ll take a look at the left too). I believe I then will go back in 3 weeks after that (I’m not exactly sure if they will start adjusting the left eye first or wait an extra week until they can adjust both at the same time since I’m doing both eyes).

My left sees and feels so much better that I can actually walk outside with only the clear UV blockers and not be blinded by the sun. My brain seems to completely ignore the right eye altogether.

Hope that helps any of you who need info to help you make decisions.

If you’d like to know about the drops, and how to apply them, it is not long but I need to sleep. I imagine it is probably very similar to what you have to do for other lenses except that you have to apply the drops in darkness. Let me know if you need any other details.

9

Thank you for your detailed post but as I wrote in my first post and to avoid misconceptions: I do have trifocal IOLs already! ZEISS AT Lisa toric which are similiar to the PanOptix IOL. Surgery done five months ago, bilateral. I’m suffering from severe dysphotopsia since then which means concentric rings and huge spiderwebs around point light sources e.g. headlights, brakelights from cars, traffic lights, street lights, bicycles and others. They didn’t decline so far. In addition I had rotation and rerotation in a second surgery but one IOL is still out off axis which shouldn’t happen with a toric one. There is significant astigmatism in both eyes. I’m now needing several glasses. For my work I have to put two glasses on my nose because varifocals or multifocal contacts do not work with trifocal IOLs.

The alternative for me now is explantation and getting a monofocal or LAL. After my experiences I will never let a diffractive lens enter my eyes - whether it’s trifocal or EDOF. The LAL is no diffractive lens.

10

Thank you for sharing your experience and for your detailed and encourageing reply! First patient here with real experience with the LAL!!! It seems that you have made a good decision. Congratulations!

To me: I received two trifocals IOLs five months ago which are similiar to the PanOptix. At that time I have never heard and wasn’t told by the doctors of the light adjustable lens. After the surgery there was rotation of one lens and I had retotation in a second surgery but the lense is still out off axis which shouldn’t happen with a toric one. I received significant residual astigmatism in both eyes. I’m now needing several glasses. For my work I have to put two glasses on my nose because varifocals or multifocal contacts are not possible with trifocal implants. I didn’t wear glasses before the surgery (only rigid contacts).
In addition I’m suffering from severe dysphotopsia caused by the diffractive optic of the IOL. Nightdriving is awful because every headlight, brakelight, traffic lights, street lights and other sources are surrounded by very bright concentric rings with huge size - they are similiar to spiderweb patterns (up to 12 rings). The farer away the bigger the circles. Even indoor LED lights are surrounded by those rings. You get the dyshotopsia during daylight as well depending on the sun. Cars or traffic lights are looking like monsters if they are approaching. Sometimes you can’t see the object behind the light - asking yourself whether it is a car, a motorbike or a bicycle.

Therefore my alternative now is explantation of the trifocal implants and receiving neither a monofocal or a light adjustable lens. I very much appreciate the concept of the LAL because there is no diffractive optic, therefore no trifocal halos. And that you can adjust the refraction of the lens after implantion when the lens is stable and in place.

My question is if the LAL works far, intermediate and near without spectacles needed. If you could ask this your surgeon that would be great. For my work I do need seamless sharp vision from 40-80 cm. This is demanding. I must be able to read small print, permantely changing sizes of letters and figures in different distances and in a wider range on my desktop with two laptops used simultanously. Longdistant nightdriving and reading the dashboard clearly must be possible as well.

Did your doctor ask you before surgery which distance you want to choose for your lenses - far or short? That’s the question if you are going with a monofocal implant.
And finally: How does the UV-light creates the refraction needed to meet the patients expectations? Not chemically but referring to the optic. As far as I understand there is no diffraction. Is it refractive? Where are the limits and drawbacks of the LAL?

It is also encourageing to hear that a catarct surgeon opted himself for the LAL. I guess you will stay in touch with him to see how it works out for him. As a cataract surgeon clear vision is absolutely vital and near vision must be great with the LAL.

Thank you so much! I’m looking forward to your answer.

11

i’m going to Codet on March 22 for the LAL. I’m 62 and high myopic ( -9 ). Right eye dominant, and have been in monovision ( contacts ) for the last 12 years. Left eye ( close ) cataract is alot worse then right. Hated monovision since day one, but needed the precise close vision for my work. I’m going there because of the EDOF enhancement that they offer. They do the exam on a Monday or Tuesday, first eye on Wednesday, follow-up on Thursday, second eye on Friday, follow-up Saturday. If everything is cool, you go home. Let me know if you have any questions and i’ll ask them. My exam is on Tuesday and I’ll get the answers then post them after i get done.

12

I’m going to get this done in about a week and would very much like to know about the drops. Thank you.

13

First, I am sorry to hear about your outcome with the trifocal. This is about as scary as it gets.

ClaudiaRM had a Trifocal implanted and also had a very bad outcome so she explanted it and implanted a traditional monofocal IOL. She now seems to be happy with the monofocal. Suggestion you check out her post on her experience and PM her.

The LAL is typically used as a monofocal. I have read that the Codet Vision Institute has / is experimenting using the LAL in other configurations.

I want to comment on distance vision. Some people I think are confused by that term. If you look at the defocus curve on a monofocal you should get pretty good vision down to about 2-3’. As you get in closer; vision quality drops off rapidly. But everyone results vary.

Until there is a truly adaptive lens like the Juvene IOL there are going to be tradeoffs in achieving close vision. If the LAL is configured for EDOF optics IMHO there are tradeoffs. I would suggest you email or call the Codet Vision Institute and see the defocus curve and how that EDOF is obtained. I remember when the Symfony IOL first came out and the trial data showed it had the same dysphotopsias as a monofocal, which was shown to be false as more people were implanted with the lens.

Dr. Shannon Wong has done youtube videos where he has explanted a Trifocal and implanted a Symfony and visa versa. So he has experience in this area. Check out his videos and email him and see what he suggest. I have emailed him and he has responded.

Final thought, if you want to avoid dysphotopsias as much as possible and still get what I call “functional close”, which means you can read your phone, menus, and labels at a grocery store, but still might need readers to do heavy book reading; I would suggestion looking at the IQ Vivity with the dominate eye set to Plano and the non dominate eye set to -.75D. There also will be more Ophthalmologist with experience with the IQ Vivity than the LAL that you can consult with.

14

I have researched the LAL being used as an EDOF and only have found a sentence here and there about it. From what I have read only the Codet Vision Institute in Mexico is trying the EDOF configuration, so you would be a brave early adaptor.

Do you have links to articles providing details about the LAL being used as an EDOF and the statistically results. One feature that would be very nice is if the EDOF did not work for someone if they could adjust the lens back on a standard monofocal.

15

I believe the most common descriptions of the various types of monovision is based on the anisometropia or difference between the two eyes:

< 1.0 D - micro monovision
1.0 - 1.5 D - mini monovision
1.5 - 2.5 D - monovision

The significant loss of stereoacuity occurs when you go over 1.5 D of anisometropia. 1.0 D is a very minimal loss. See the graph below. This is one of the reason I will go for 1.25 D if I go for monovison. It seems to be a good compromise. With Vivity as we have discussed before, I would go for less, or more like -0.75 D. But I am cooling off on Vivity for other reasons, and am pretty sure now I will use a standard monofocal lens.
.

16

Did your doctor ask you before surgery which distance you want to choose for your lenses - far or short? That’s the question if you are going with a monofocal implant.

And finally: How does the UV-light creates the refraction needed to meet the patients expectations? Not chemically but referring to the optic. As far as I understand there is no diffraction. Is it refractive? Where are the limits and drawbacks of the LAL?>

No, he did not ask me. I was initially looking for the Vivity lens which uses a unique way to achieve EDOF but while I was visiting one of the first clinics to have worked with the Vivity lens, they told me that the LAL was available. That lens was chosen because I had had Lasik before and that procedure throws an unpredictable variable in the final “shape” of the eye when healed. So I was told that the LAL is ideal for post lasik cataract since the type of vision one wants can be dialed in post healing.

There is no need to choose between close or far since the adjustments can allow you to try either or both and when you are satisfied, you can choose the combination (or compromise) you end up preferring. The following is almost word for word what is in my FAQs. the last two sentences are verbatim since I realized that I was basically retyping what they had.

The lens has particles (macromers) distributed throughout the lens and the UV light source called the LDD (light delivery device) is used to change the shape and focusing characteristics of the lens. The light when directed at specific areas of the lens causes the particles in the path of the light to connect with other particles and form polymers. “The remaining unconnected particles then move to the exposed area. This movement causes a highly predictable change in the curvature of the lens. The new shape of the lens will match the prescription you selected during your eye exam.”

It is refractive.

I don’t know of any limits but the drawback is that it does change shape and get larger so if for some reason it needs to be removed, it has to be cut into several pieces in order to be removed.

17

The drops I believe are standard for cataract, they are called combo drops and are made up of Prednisone Acetate, Moxifloxacin and Bromfenac.

You start putting one drop in the eye that will be operated on, 3 days before then once a day everyday post-op. Post-op, you must put the drops in total darkness which is awkward so I sometimes end up dropping 2 drops just to make sure I got one in there.

They ask that you put on an eye shield when you go to sleep for 3 days after the surgery.

18

I too was talked into monovision when I got lasik and HATED IT, so I went back in and asked to have them be the same but again let him talk me into “mini-mono” which I hated only slightly less.

As for having to go to special clinic for EDOF, I’d be very skeptical. It is my belief (and experience thus far) that the lens is inherently EDOF. I have not had monofocals so I am not precisely certain how it works but if it is the same thing as in photography, it seems as though it refers to having a very limited depth of field. I did not ask for anything special with my IOL and have not gone through any adjustments yet but my left eye seems to see like it always has except for trying to read small print very close up (closer than about 14-15 inches (about 3-3.5" beyond my elbow). I can see clearly close, intermediate and very far.

I cannot say whether this is typical or not but this is what I am experiencing. YMMV.

19

The company is betting millions of $ that the edof is a very significant upgrade. It’s going into trials in the U.S right now. Won’t be available here for for 2 years. My left eye , like yours, is about useless. When I get there I will find out the details and decide then. I wanted the option to avoid any monovision so this is the only place to go.

20

Big thanks for the info. I’ve never tried to put drops in the darkness so I guess I should start practicing.